Breastcancerchoices.org
he only trouble with scientific medicine was that it was not scientific enough.    
   -- Renéé Dubos
GENERIC CONSENT FORM FOR CHEMOTHERAPY TREATMENT

I understand that State law guarantees my right to receive information about my
health care to make decisions about my health care in partnership with my physician.

I hereby authorize Dr. __________ and his/her associates to treat my
____________.  I understand they will plan and administer cancer treatment
medication(s), which are intended to control my disease, by destroying abnormal
cells, reducing the risk of lesion growth or re-growth, and preventing or relieving
symptoms which may be caused by the disease.  These medications may include
some of the following: ______________________________.

I authorize my oncology physicians and their associates to carry out the procedures
necessary to give me cancer treatment, including, but not limited to:  laboratory tests,
diagnostic X-ray exams, tissue biopsies, and gathering and recording medical
information about me.

This cancer treatment may require the need to have an intravenous (IV) line inserted
into my body.  This could be with a short-term type of IV placed by a nurse, or a
longer-term type of catheter, placed by a physician.  In addition, this treatment may
require the administration of medication to minimize side effects such as allergic
reactions or nausea and vomiting.

Patients receiving this treatment frequently experience side effects which may
include, but are not limited to: nausea, vomiting, diarrhea, allergic reactions, hair
loss, mouth sores, fatigue, numbness and tingling of toes and fingers, and bone
marrow suppression with the risk of infection, anemia, and bleeding,
___________________________________________________________________
____________________________________________.

For several weeks after the course of treatment I may be very tired;  full recovery
from cancer medication treatments may require several months.

In addition to the short term side effects of treatments, there is a risk of major
complications, which may be be permanent or may require medical or surgical
treatments, including but not limited to: organ damage, tissue injury secondary to
leakage of chemotherapy under the skin and
infertility,____________________________________________________________
________________________________.

There is a small risk that the chemotherapy treatment could cause a new cancer or
could result in permanent disability or death.


I have been informed of the benefits and anticipated outcomes of this proposed
treatment as well as anticipated problems that may occur related to recuperation
from this treatment. I have also been informed of the benefits, risks, and
consequences of alternative forms of treatment, as well as the likely results if I
choose not to be treated.

I recognize that during the course of my evaluation and treatment, unexplained
conditions may be discovered, which may require additional or different procedures
than those mentioned above.  I therefore authorize my oncology physician or nurse
practitioner to evaluate and treat me in accordance with their best professional
judgment.

I understand that cancer treatment medication may be harmful to human eggs or
sperm and to the developing embryo or fetus.  I certify that I am not pregnant now
and will avoid becoming pregnant or fathering children during my treatment and for
six month afterward.  If there is any chance that I may be pregnant or become
pregnant, I will tell my oncology physician or nurse practitioner immediately.

I recognize that there can be no guarantee of benefit or cure from the treatment and
no assurance that side effects or complications of treatment will not occur.  I freely
consent to this treatment, knowing that I have the right to ask additional questions,
refuse or withdraw from treatment at any time without affecting my access to care.

I acknowledge that my physician or nurse practitioner and I have discussed the
information set forth above and that my questions have been answered to my
satisfaction.

By signing below I also certify that this form has been fully explained to me, that I
have read it or have had it read to me, that the blanks have been filled in, that I
understand its contents, and that I have received a copy. I make this request for
treatment and grant the authority set forth above voluntarily, and assume
responsibility for my decision.

_____________________                        _____________________________
Date                                             Signature of Patient or Legal
                      Guardian

______________________                     ______________________________
Physician/Nurse                                           Witness
Practitioner